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  • 101.
    Ram Jat, Tej
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Deo, PR
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastian, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sociocultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lensInngår i: Artikkel i tidsskrift (Fagfellevurdert)
  • 102.
    Rocklöv, Joacim
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap. Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Forsberg, Bertil
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Yrkes- och miljömedicin.
    Hälsopåverkan av ett varmare klimat: en kunskapsöversikt2008Rapport (Annet vitenskapelig)
  • 103.
    Ruano, Ana Lorena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastían, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    'If no one else stands up, you have to': a story of community participation and water in rural Guatemala2011Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 4, s. Article nr 6412-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Access to water is a right and a social determinant of health that should be provided by the state. However, when it comes to access to water in rural areas, the current trend is for communities to arrange for the service themselves through locally run projects. This article presents a narrative of a single community's process of participation in implementing and running a water project in the village of El Triunfo, Guatemala.

    METHODS: Using an ethnographic approach, we conducted a series of interviews with five village leaders, field visits, and participant observations in different meetings and activities of the community.

    FINDINGS: El Triunfo has had a long tradition of community participation, where it has been perceived as an important value. The village has a council of leaders who have worked together in various projects, although water has always been a priority. When it comes to participation, this community has achieved its goals when it collaborated with other stakeholders who provided the expertise and/or the funding needed to carry out a project. At the time of the study, the challenge was to develop a new phase of the water project with the help of other stakeholders and to maintain and sustain the tradition of participation by involving new generations in the process.

    DISCUSSION: This narrative focuses on the participation in this village's efforts to implement a water project. We found that community participation has substituted the role of the central and local governments, and that the collaboration between the council and other stakeholders has provided a way for El Triunfo to satisfy some of its demand for water.

    CONCLUSION: El Triunfo's case shows that for a participatory scheme to be successful it needs prolonged engagement, continued support, and successful experiences that can help to provide the kind of stable participatory practices that involves community members in a process of empowered decision-making and policy implementation.

  • 104.
    Ruano, Ana Lorena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hernández, Alison
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Dahlblom, Kjerstin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    ‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala2012Inngår i: Archives of Public Health, ISSN 0778-7367, E-ISSN 2049-3258, Vol. 70, s. 18-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s healthissues required more than just hospital-based and physician-centered policies. The declaration called for a paradigmchange that would allow governments to provide essential care to their population in a universally acceptablemanner. The figure of the community health worker (CHW) remains a central feature of participation within thePHC approach, and being a CHW is still considered to be an important way of participation within the healthsystem.Methods: This study explores how the values and personal motivation of community health workers influencestheir experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, weused an ethnographic approach and collected data in January-March of 2009 and 2010 by using participantobservation and in-depth interviews.Results: We found that the CHWs in the municipality had a close working relationship with the mobile health teamand with the community, and that their positions allowed them to develop leadership and teamwork skills that mayprove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is akey value in Palencia, but there is a lack of infrastructure and growth opportunities.Conclusion: Attention should be paid to keeping the high levels of commitment and integration within the healthteam as well as keeping up supervision and economic funds for the program.

  • 105.
    Ruano, Ana Lorena
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    San Sebastián Chasco, Miguel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    The process of social participation in primary health care: the case of Palencia, Guatemala2014Inngår i: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, nr 1, s. 93-103Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background In 2008, the World Health Organization issued a callback to the principles of primary health care, which renewed interests in social participation in health. In Guatemala, social participation has been the main policy for the decentralization process since the late 1990s and the social development council scheme has been the main means for participation for the country's population since 2002.

    Aim The aim of this study was to explore the process of social participation at a municipal-level health commission in the municipality of Palencia, Guatemala.

    Methods Analysis of legal and policy documents and in-depth interviews with institutional and community-level stakeholders of the commission.

    Results The lack of clear guidelines and regulations means that the stakeholders own motivations, agendas and power resources play an important part in defining the roles of the participants. Institutional stakeholders have the human and financial power to make policies. The community-level stakeholders are token participants with little power resources. Their main role is to identify the needs of their communities and seek help from the authorities. Satisfaction and the perceived benefits that the stakeholders obtain from the process play an important part in maintaining the commission's dynamic, which is unlikely to change unless the stakeholders perceive that the benefit they obtain does not outweigh the effort their role entails.

    Conclusion Without more uniformed mechanisms and incentives for municipalities to work towards the national goal of equitable involvement in the development process, the achievements will be fragmented and will depend on the individual stakeholder's good will.

  • 106.
    Rusanganwa, Vincent
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Avdelningen för virologi. University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda.
    Gahutu, Jean Bosco
    University of Rwanda, College of Medicine and Health Sciences, Kigali, Rwanda.
    Evander, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Avdelningen för virologi.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Clinical Referral Laboratory Personnel’s Perception of Challenges and Strategies for Sustaining the Laboratory Quality Management System: A Qualitative Study in Rwanda2019Inngår i: American Journal of Clinical Pathology, ISSN 0002-9173, E-ISSN 1943-7722Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives: To explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services.

    Methods: Twenty key informants’ interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis.

    Results: Two themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders’ communication contributed to low-quality performance.

    Conclusions: The coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

  • 107.
    Rusanganwa, Vincent
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Avdelningen för virologi.
    Gahutu, Jean Bosco
    Nzabahimana, Innocent
    Ngendakabaniga, Jean Marie Vianney
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Evander, Magnus
    Umeå universitet, Medicinska fakulteten, Institutionen för klinisk mikrobiologi, Avdelningen för virologi.
    Clinical Referral Laboratories in Rwanda: The Status of Quality Improvement After 7 Years of the SLMTA Program2018Inngår i: American Journal of Clinical Pathology, ISSN 0002-9173, E-ISSN 1943-7722, Vol. 150, nr 3, s. 240-245Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Objectives: We investigated the quality system performance in Rwandan referral laboratories to determine their progress toward accreditation.

    Methods: We conducted audits across five laboratories in 2017, using the Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist. Laboratories were scored based on the World Health Organization grading scale (0-5 stars scale) and compared with earlier audits.

    Results: Between 2012 and 2017, only one laboratory progressed (from four to five stars). Four of the five laboratories decreased to one (three laboratories) and zero (one laboratory) stars from four and three stars. Management reviews, evaluation, audits, documents, records, and identification of nonconformities showed a low performance.

    Conclusions: Four of five laboratories are not moving toward accreditation. However, this target is still achievable by energizing responsibilities of stakeholders and monitoring and evaluation. This would be possible because of the ability that laboratories showed in earlier audits, coupled with existing health policy that enables sustainable quality health care in Rwanda.

  • 108.
    San Sebastian Chasco, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Review of health research on indigenous populations in Latin America, 1995-2004.2007Inngår i: Salud Publica Mex, ISSN 0036-3634, Vol. 49, nr 4, s. 316-320Artikkel i tidsskrift (Fagfellevurdert)
  • 109.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Oil development and health in the Amazon basin of Ecuador: the popular epidemiology process.2005Inngår i: Soc Sci Med, ISSN 0277-9536, Vol. 60, nr 4, s. 799-807Artikkel i tidsskrift (Fagfellevurdert)
  • 110.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    A new leadership for UNICEF: do values matter?2005Inngår i: Lancet, ISSN 1474-547X, Vol. 365, nr 9465, s. 1136-7Artikkel i tidsskrift (Annet vitenskapelig)
  • 111.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Cancer among indigenous people in the Amazon Basin of Ecuador, 1985-2000.2004Inngår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 16, nr 5, s. 328-33Artikkel i tidsskrift (Fagfellevurdert)
  • 112.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Is GATS a concern for the Swedish healthcare system?2007Inngår i: Scand J Public Health, ISSN 1403-4948, s. 1-4Artikkel i tidsskrift (Fagfellevurdert)
  • 113.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Moving on from NAFTA to the FTAA?: the impact of trade agreements on social and health conditions in the Americas.2004Inngår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 16, nr 4, s. 272-8Artikkel i tidsskrift (Fagfellevurdert)
  • 114.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Oil exploitation in the Amazon basin of Ecuador: a public health emergency.2004Inngår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 15, nr 3, s. 205-11Artikkel i tidsskrift (Fagfellevurdert)
  • 115.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Sachiapi Tapusa: health research in the Amazon bwsin of Ecuador, 1998-2003 [in spanish]2005Rapport (Annet (populærvitenskap, debatt, mm))
  • 116.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Breilh, Jaime
    Peralta, Arturo Quizhpe
    [The People's Health Movement: health for all now.]2005Inngår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 18, nr 1, s. 45-9Artikkel i tidsskrift (Fagfellevurdert)
  • 117.
    San Sebastian, Miguel
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och folkhälsovetenskap.
    Rasanathan, Kumanan
    Is trade liberalization of services the best strategy to achieve health-related Millennium Development Goals in Latin America? A call for caution.2006Inngår i: Rev Panam Salud Publica, ISSN 1020-4989, Vol. 20, nr 5, s. 341-6Artikkel i tidsskrift (Fagfellevurdert)
  • 118. Schneider, Helen
    et al.
    Zulu, Joseph Mumba
    Mathias, Kaaren
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Emmanuel Hospital Association, New Delhi, Delhi, India.
    Cloete, Keith
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts2019Inngår i: BMJ Global Health, ISSN 2059-7908, Vol. 4, nr 3, artikkel-id e001645Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This analysis reflects on experiences and lessons from four country settings-Zambia, India, Sweden and South Africa-on building collaborations in local health systems in order to respond to complex health needs. These collaborations ranged in scope and formality, from coordinating action in the community health system (Zambia), to a partnership between governmental, nongovernmental and academic actors (India), to joint planning and delivery across political and sectoral boundaries (Sweden and South Africa). The four cases are presented and analysed using a common framework of collaborative governance, focusing on the dynamics of the collaboration itself, with respect to principled engagement, shared motivation and joint capacity. The four cases, despite their differences, illustrate the considerable challenges and the specific dynamics involved in developing collaborative action in local health systems. These include the coconstruction of solutions (and in some instances the problem itself) through engagement, the importance of trust, both interpersonal and institutional, as a condition for collaborative arrangements, and the role of openly accessible information in building shared understanding. Ultimately, collaborative action takes time and difficulty needs to be anticipated. If discovery, joint learning and developing shared perspectives are presented as goals in themselves, this may offset internal and external expectations that collaborations deliver results in the short term.

  • 119. Simms, I
    et al.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Rogers, P A
    Hughes, G
    Fenton, K A
    Surveillance of sexually transmitted infections in primary care.2003Inngår i: Sexually Transmitted Infections, ISSN 1368-4973, E-ISSN 1472-3263, Vol. 79, nr 3, s. 174-6Artikkel i tidsskrift (Fagfellevurdert)
  • 120.
    Sirili, Nathanael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Frumence, Gasto
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kiwara, A
    Mwangu, M
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    "Doctors ready to be posted are jobless on the street..." the deploymnet process and shortage of doctors in TanzaniaManuskript (preprint) (Annet vitenskapelig)
  • 121.
    Sirili, Nathanael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kiwara, Angwara
    Mwangu, Mughwira
    Anaeli, Amani
    Nyamhanga, Tumaini
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Retention of medical doctors at the district level: a qualitative study of experiences from Tanzania2018Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, artikkel-id 260Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Retention of Human Resources for Health (HRH), particularly doctors at district level is a big challenge facing the decentralized health systems in poorly resourced countries. Tanzania, with 75% of its population in rural areas, has only 26% of doctors serving in rural areas. We aimed to analyze the experiences regarding the retention of doctors at district level in Tanzania from doctors' and district health managers' perspectives.

    METHODS: A qualitative study was carried out in three districts from June to September 2013. We reviewed selected HRH documents and then conducted 15 key informant interviews with members of the District Health Management teams and medical doctors working at the district hospitals. In addition, we conducted three focus group discussions with Council Health Management Team members in the three districts. Incentive package plans, HRH establishment, and health sector development plans from the three districts were reviewed. Data analysis was performed using qualitative content analysis.

    RESULTS: None of the districts in this study has the number of doctors recommended. Retention of doctors in the districts faced the following challenges: unfavourable working conditions including poor working environment, lack of assurance of career progression, and a non-uniform financial incentive system across districts; unsupportive environment in the community, characterized by: difficulty in securing houses for rent, lack of opportunities to earn extra income, lack of appreciation from the community and poor social services. Health managers across districts endeavour to retain their doctors through different retention strategies, including: career development plans, minimum financial incentive packages and avenues for private practices in the district hospitals. However, managers face constrained financial resources, with many competing priorities at district level.

    CONCLUSIONS: Retention of doctors at district level faces numerous challenges. Assurance of career growth, provision of uniform minimum financial incentives and ensuring availability of good social services and economic opportunities within the community are among important retention strategies.

  • 122.
    Sirili, Nathanael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Kiwara, Angwara
    Mwangu, Mughwira
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin.
    "Doctors ready to be posted are jobless on the street…" the deployment process and shortage of doctors in Tanzania.2019Inngår i: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, nr 1, artikkel-id 11Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: The World Health Organization advocates that health workforce development is a continuum of three stages of entry, available workforce and exit. However, many studies have focused on addressing the shortage of numbers and the retention of doctors in rural and remote areas. The latter has left the contribution of the entry stage in particularly the deployment process on the shortage of health workforce less understood. This study therefore explored the experiences of medical doctors (MDs) on the deployment process after the internship period in Tanzania's health sector.

    METHODS: A qualitative case study that adopted chain referral sampling was used to conduct 20 key informant interviews with MDs who graduated between 2003 and 2009 from two Medical Universities in Tanzania between February and April 2016. These MDs were working in hospitals at different levels and Medical Universities in eight regions and five geo-political zones in the country. Information gathered was analysed using a qualitative content analysis approach.

    RESULTS: Experiences on the deployment process fall into three categories. First, "uncertainties around the first appointment" attributed to lack of effective strategies for identification of the pool of available MDs, indecision and limited vacancies for employment in the public sector and private sector and non-transparent and lengthy bureaucratic procedures in offering government employment. Second, "failure to respect individuals' preferences of work location" which were based on the influence of family ties, fear of the unknown rural environment among urbanized MDs and concern for career prospects. Third, "feelings of insecurity about being placed at a regional and district level" partly due to local government authorities being unprepared to receive and accommodate MDs and territorial protectionism among assistant medical officers.

    CONCLUSIONS: Experiences of MDs on the deployment process in Tanzania reveal many challenges that need to be addressed for the deployment to contribute better in availability of equitably distributed health workforce in the country. Short-term, mid-term and long-term strategies are needed to address these challenges. These strategies should focus on linking of the internship with the first appointment, work place preferences, defining and supporting career paths to health workers working under the local government authorities, improving the working relationships and team building at the work places and fostering rural attachment to medical students during medical training.

  • 123.
    Sirili, Nathanael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O.BOX 65454, Dar es Salaam, Tanzania.
    Frumence, Gasto
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kiwara, Angwara
    Mwangu, Mughwira
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Public private partnership in training of doctors after the 1990s' health sector reforms: the case of Tanzania2019Inngår i: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 17, artikkel-id 33Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s’ health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s’ health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities’ autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

  • 124. Sirili, Nathanael
    et al.
    Kiwara, Angawara
    Nyongole, Obadia
    Frumence, Gasto
    Semakafu, Avemaria
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Addressing the human resource for health crisis in Tanzania: The lost in transition syndrome2014Inngår i: Tanzania Journal of Health Research, ISSN 1821-6404, Vol. 16, nr 2Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Tanzania is experiencing a serious Human Resource for Health (HRH) crisis. Shortages are 87.5% and 67% in private and public hospitals, respectively. Mal-distribution and brain drain compound the shortage. The objective of this study was to improve knowledge on the HRH status in Tanzania by analyzing what happens to the number of medical doctors (MD) and doctor of dental surgery (DDS) degree graduates during the transition period from graduation, internship to appointment. We analyzed secondary data to get the number of MDs and DDS; who graduated from 2001 to 2010, the number registered for internship from 2005 to 2010 and the number allowed for recruitment by government permits from 2006 to 2010. Self administered questionnaires were provided to 91 MDs and DDS who were pursuing postgraduate studies at Muhimbili University of Health and Allied Sciences during this study who went through the graduation-internship-appointment (GIA) period to get the insight of the challenges surrounding the MDs and DDS during the GIA period. From 2001 to 2010 a total of 2,248 medical doctors and 198 dental surgeons graduated from five local training institutions and abroad. From 2005 to 2010 a total of 1691 (97.13%) and 186 (126.53%) of all graduates in MD and DDS, respectively, registered for internship. The 2007/2008 recruitment permit allowed only 37.7% (80/218) and 25.0% (7/27) of the MDs and DDS graduated in 2006, respectively. The 2009/2010 recruitment permit allowed 265 MDs (85.48%) out of 310 graduates of 2008. In 2010/2011 permission for MDs was 57.58% (190/ 330) of graduates of 2009 and in 2011/2012 permission for MDs was for 61.03% ((249/408) graduates of 2010. From this analysis the recruitment permits in 2007/2008, 2009/2010, 2010/2011 1nd 2011/2012 could not offer permission for employment of 482 (38.10%) of all MDs graduated in the subsequent years. Major challenges associated with the GIA period included place of accommodation, allowance (for internship) or salary delay (for first appointment), difficulty working environment, limited carrier opportunities and concern for job security. The failure to enforce mandatory registration for internship and failure to absorb all produced MDs and DDS results to loss of a substantial number of these graduates during the graduation-internshipappointment period. To solve this problem, it is recommended to establish better human resource for health management system.

  • 125.
    Sirili, Nathanael
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
    Kiwara, Angwara
    Gasto, Frumence
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Training and deployment of medical doctors in Tanzania post-1990s health sector reforms: assessing the achievements2017Inngår i: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 15, artikkel-id 27Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: The shortage of a skilled health workforce is a global crisis. International efforts to combat the crisis have shown few benefits; therefore, more country-specific efforts are required. Tanzania adopted health sector reforms in the 1990s to ensure, among other things, availability of an adequate skilled health workforce. Little is documented on how the post-reform training and deployment of medical doctors (MDs) have contributed to resolving Tanzania's shortage of doctors. The study aims to assess achievements in training and deployment of MDs in Tanzania about 20 years since the 1990s health sector reforms.

    METHODS: We developed a human resource for health (HRH) conceptual model to study achievements in the training and deployment of MDs by using the concepts of supply and demand. We analysed secondary data to document the number of MDs trained in Tanzania and abroad, and the number of MDs recommended for the health sector from 1992 to 2011. A cross-sectional survey conducted in all regions of the country established the number of MDs available by 2011.

    RESULTS: By 1992, Tanzania had 1265 MDs working in the country. From 1992 to 2010, 2622 MDs graduated both locally and abroad. This translates into 3887 MDs by 2011. Tanzania needs between 3326 and 5535 MDs. Our survey captured 1299 MDs working throughout the country. This number is less than 40% of all MDs trained in and needed for Tanzania by 2011. Maldistribution favouring big cities was evident; the eastern zone with less than 30% of the population hosts more than 50% of all MDs. No information was available on the more than 60% of MDs uncaptured by our survey.

    CONCLUSIONS: Two decades after the reforms, the number of MDs trained in Tanzania has increased sevenfold per year. Yet, the number and geographical distribution of MDs practicing in the country has remained the same as before the reforms. HRH planning should consider the three stages of health workforce development conceptualized under the demand and supply model. Auditing and improvement of the HRH database is highly recommended in dealing with Tanzania's MD crisis.

  • 126.
    Sundqvist, Johanna
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    Padyab, Mojgan
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ghazinour, Mehdi
    Umeå universitet, Samhällsvetenskapliga fakulteten, Institutionen för socialt arbete. Umeå universitet, Samhällsvetenskapliga fakulteten, Enheten för polisutbildning vid Umeå universitet.
    The association between social support and the mental health of social workers and police officers who work with unaccompanied asylum-seeking refugee children’s forced repatriation: a Swedish experience2018Inngår i: International Journal of Mental Health, ISSN 0020-7411, E-ISSN 1557-9328, Vol. 47, nr 1, s. 3-25Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    This study aims to contribute to the knowledge of social support and its association with mental health amongst social workers and police officers in forced repatriation work of unaccompanied asylum-seeking refugee children. Nationally distributed surveys to social workers and police officers with and without experience of forced repatriation were used, measured by an abbreviated version of the Interview Schedule for Social Interaction (ISSI), and analyzed by univariate and multivariable regression models. Social workers in forced repatriation showed significantly poorer mental health than other social workers, but simultaneously relatively high access to social support. Irrespective of working with forced repatriation, police officers reported relatively high access to social support, but no difference in mental health. Furthermore, low levels of satisfaction with social interaction and close emotional support increased the odds of psychological disturbances for police officers in forced repatriation. Findings are discussed with special regard to the complexity of forced repatriation, particularly when children are the focus.

  • 127.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Bennett, Sara
    Kiwanuka, Suzanne N.
    George, Asha
    Kiracho, Elizabeth Ekirapa
    A participatory action research approach to strengthening health managers' capacity at district level in Eastern Uganda2017Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 15, artikkel-id 110Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Many approaches to improving health managers' capacity in poor countries, particularly those pursued by external agencies, employ non-participatory approaches and often seek to circumvent (rather than strengthen) weak public management structures. This limits opportunities for strengthening local health managers' capacity, improving resource utilisation and enhancing service delivery. This study explored the contribution of a participatory action research approach to strengthening health managers' capacity in Eastern Uganda.

    Methods: This was a qualitative study that used open-ended key informant interviews, combined with review of meeting minutes and observations to collect data. Both inductive and deductive thematic analysis was undertaken. The Competing Values Framework of organisational management functions guided the deductive process of analysis and the interpretation of the findings. The framework builds on four earlier models of management and regards them as complementary rather than conflicting, and identifies four managers' capacities (collaborate, create, compete and control) by categorising them along two axes, one contrasting flexibility versus control and the other internal versus external organisational focus.

    Results: The findings indicate that the participatory action research approach enhanced health managers' capacity to collaborate with others, be creative, attain goals and review progress. The enablers included expanded interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability. Tension and conflict across different management functions was apparent; for example, while there was a need to collaborate, maintaining control over processes was also needed. These tensions meant that managers needed to learn to simultaneously draw upon and use different capacities as reflected by the Competing Values Framework in order to maximise their effectiveness.

    Conclusions: Improved health manager capacity is essential if sustained improvements in health outcomes in low-income countries are to be attained. The expansion of interaction spaces, encouragement of flexibility, empowerment of local managers, and the promotion of reflection and accountability were the key means by which participatory action research strengthened health managers' capacity. The participatory approach to implementation therefore created opportunities to strengthen health managers' capacity.

  • 128.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirapa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda2017Inngår i: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, artikkel-id 1346038Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions.

    OBJECTIVE: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity.

    METHODS: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders' experiences.

    RESULTS: 'Being awakened' emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration.

    CONCLUSIONS: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.

  • 129.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University School of Public Health (MakSPH), Makerere University, New Mulago Complex, P.O. B0X 7072, Kampala, Uganda.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirpa-Kiracho, Elizabeth
    Kiwanuka, Suzanne N.
    Coe, Anna-Britt
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Building a competent health manager at district level: a grounded theory study from Eastern Uganda2016Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, artikkel-id 665Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Health systems in low-income countries are often characterized by poor health outcomes. While many reasons have been advanced to explain the persistently poor outcomes, management of the system has been found to play a key role. According to a WHO framework, the management of health systems is central to its ability to deliver needed health services. In this study, we examined how district managers in a rural setting in Uganda perceived existing approaches to strengthening management so as to provide a pragmatic and synergistic model for improving management capacity building.

    Methods: Twenty-two interviews were conducted with district level administrative and political managers, district level health managers and health facility managers to understand their perceptions and definitions of management and capacity building. Kathy Charmaz's constructive approach to grounded theory informed the data analysis process.

    Results: An interative, dynamic and complex model with three sub-process of building a competent health manager was developed. A competent manager was understood as one who knew his/her roles, was well informed and was empowered to execute management functions. Professionalizing health managers which was viewed as the foundation, the use of engaging learning approaches as the inside contents and having a supportive work environment the frame of the model were the sub-processes involved in the model. The sub-processes were interconnected although the respondents agreed that having a supportive work environment was more time and effort intensive relative to the other two sub-processes.

    Conclusions: The model developed in our study makes four central contributions to enhance the WHO framework and the existing literature. First, it emphasizes management capacity building as an iterative, dynamic and complex process rather than a set of characteristics of competent managers. Second, our model suggests the need for professionalization of health managers at different levels of the health system. Third, our model underscores the benefits that could be accrued from the use of engaging learning approaches through prolonged and sustained processes that act in synergy. Lastly, our model postulates that different resource investments and a varied range of stakeholders could be required at each of the sub-processes.

  • 130.
    Tetui, Moses
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Zulu, Joseph Mumba
    School of Public Health, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Ekirapa-Kiracho, Elizabeth
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Kiwanuka, Suzanne N.
    Makerere University College of Health Sciences, School of Public Health (MakCHS-SPH), Kampala, Uganda.
    Coe, Anna-Britt
    Umeå universitet, Samhällsvetenskapliga fakulteten, Sociologiska institutionen.
    Elements for harnessing participatory action research to strengthen health managers’ capacity: a critical interpretative synthesis2018Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 16, artikkel-id 33Artikkel, forskningsoversikt (Fagfellevurdert)
    Abstract [en]

    Background: Health managers play a key role in ensuring that health services are responsive to the needs of the population. Participatory action research (PAR) is one of the approaches that have been used to strengthen managers’ capacity. However, collated knowledge on elements for harnessing PAR to strengthen managers’ capacity is missing. This paper bridges this gap by reviewing existing literature on the subject matter.

    Methods: A critical interpretive synthesis method was used to interrogate eight selected articles. These articles reported the use of PAR to strengthen health managers’ capacity. The critical interpretive synthesis method’s approach to analysis guided the synthesis. Here, the authors interpretively made connections and linkages between different elements identified in the literature. Finally, the Atun et al. (Heal Pol Plann, 25:104–111, 2010) framework on integration was used to model the elements synthesised in the literature into five main domains.

    Results: Five elements with intricate bi-directional interactions were identified in the literature reviewed. These included a shared purpose, skilled facilitation and psychological safety, activity integration into organisational procedures, organisational support, and external supportive monitoring. A shared purpose of the managers’ capacity strengthening initiative created commitment and motivation to learn. This purpose was built upon a set of facilitation skills that included promoting participation, self-efficacy and reflection, thereby creating a safe psychological space within which the managers interacted and learnt from each other and their actions. Additionally, an integrated intervention strengthened local capacity and harnessed organisational support for learning. Finally, supportive monitoring from external partners, such as researchers, ensured quality, building of local capacity and professional safety networks essential for continued learning.

    Conclusions: The five elements identified in this synthesis provide a basis upon which the use of PAR can be harnessed, not only to strengthen health managers’ capacity, but also to foster other health systems strengthening initiatives involving implementation research. In addition, the findings demonstrated the intricate and complex relations between the elements, which further affirms the need for a systems thinking approach to tackling health systems challenges.

  • 131.
    Thomée, Suzanne
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Malm, Desiré
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Christianson, Monica
    Umeå universitet, Medicinska fakulteten, Institutionen för omvårdnad.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Wiklund, Maria
    Umeå universitet, Medicinska fakulteten, Institutionen för samhällsmedicin och rehabilitering, Fysioterapi.
    Waenerlund, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Challenges and strategies for sustaining youth-friendly health services: a qualitative study from the perspective of professionals at youth clinics in northern Sweden2016Inngår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 13, artikkel-id 147Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Youth-friendly health-care services - those that are accessible, acceptable, equitable, appropriate and effective for different youth subpopulations - are beneficial for youth health, but not easy to implement and sustain. Sweden is among the few countries where youth-friendly health-care services have been integrated within the public health system and sustained for a long time. This study explores the challenges and strategies in providing sustainable youth-friendly health-care services, from the perspective of professionals working in youth clinics in northern Sweden.

    METHODS: Eleven semi-structured interviews with various health-care professionals working in youth clinics in northern Sweden were conducted. The interviews were transcribed verbatim, and analysed using thematic analysis in relation to the World Health Organization domains of youth friendliness.

    RESULTS: Four themes emerged from the analysis of the data: 1) 'Meeting youths on their own terms - the key to ensuring a holistic and youth-centred care' was related to the acceptability and appropriateness of the services; 2) 'Organizational challenges and strategies in keeping professionals' expertise on youth updated' referred to the domain of effectiveness; 3) 'Youth clinics are accessible for those who know and can reach them' was related to the domains of accessibility and equity, and 4) 'The challenge of combining strong directions and flexibility in diverse local realities' focused on the struggle to sustain the youth clinics organization and their goals within the broader health system.

    CONCLUSIONS: Professionals working in youth clinics are perceived as motivated, interested and knowledgeable about youth, and the clinics ensure confidentiality and a youth-centred and holistic approach. Challenges remain, especially in terms of ensuring equitable access to different youth subpopulations, improving monitoring routines and ensuring training and competence for all professionals, independently of the location and characteristics of the clinic. Youth clinics are perceived as an indisputable part of the Swedish health system, but organizational challenges are also pointed out in terms of weak clear directives and leadership, heavy workload, local/regional diversity and unequitable distribution of resources.

  • 132. Zulu, Joseph M.
    et al.
    Goicolea, Isabel
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Sandøy, Ingvild Fossgard
    Blystad, Astrid
    Mulubwa, Chama
    Makasa, Mpundu C.
    Michelo, Charles
    Musonda, Patrick
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Community based interventions for strengthening adolescent sexual reproductive health and rights: how can they be integrated and sustained? A realist evaluation protocol from Zambia2018Inngår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 15, artikkel-id 145Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: Research that explores how community-based interventions for strengthening adolescent sexual reproductive health and rights (SRHR) can be integrated and sustained in community health systems, is, to the best of our knowledge, very scarce, if not absent. It is important to document mechanisms that shape integration process in order to improve health systems' responsiveness towards adolescents' SRHR. This realist evaluation protocol will contribute to this knowledge in Zambia where there is increased attention towards promoting maternal, neonatal and child health as a means of addressing the current high early pregnancy and marriage rates. The protocol will ascertain: why, how, and under what conditions the integration of SRHR interventions into Zambian community health systems will optimise (or not) acceptability and adoption of SRHR services. This study is embedded within a randomized controlled trial - "Research Initiative to Support the Empowerment of Girls (RISE) "-which aims to reduce adolescent girl pregnancies and marriages through a package of interventions including economic support to families, payment of school fees to keep girls in school, pocket money for girls, as well as youth club and community meetings on reproductive health.

    Methods: This is a multiple-case study design. Data will be collected from schools, health facilities and communities through individual and group interviews, photovoice, documentary review, and observations. The study process will involve 1) developing an initial causal theory that proposes an explanation of how the integration of a community-based intervention that aimed to integrate adolescent SRHR into the community health system may lead to adolescent-friendly services; 2) refining the causal theory through case studies; 3) identifying contextual conditions and mechanisms that shape the integration process; and 4) finally proposing a refined causal theory and set of recommendations to guide policy makers, steer further research, and inform teaching programmes.

    Discussion: The study will document relevant values as well as less formal and horizontal mechanisms which shape the integration process of SRHR interventions at community level. Knowledge on mechanisms is essential for guiding development of strategies for effectively facilitating the integration process, scaling up processes and sustainability of interventions aimed at reducing SRH problems and health inequalities among adolescents.

  • 133.
    Zulu, Joseph M.
    et al.
    University of Zambia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.
    Michelo, Charles
    University of Zambia.
    George, Asha
    University of the Western Cape.
    Schneider, Helen
    University of the Western Cape.
    Integrating community health assistant-driven sexual and reproductive health services in the community health system in Nyimba district in Zambia: mapping key actors, points of integration, and conditions shaping the process2019Inngår i: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 16, nr 1, artikkel-id 122Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Introduction: Although large scale public sector community health worker programs have been key in providing sexual and reproductive health (SRH) services in low- and middle-income countries, their integration process into community health systems is not well understood. This study aimed to identify the conditions and strategies through which Community Health Assistants (CHAs) gained entry and acceptability into community health systems to provide SRH services to youth in Zambia. The country's CHA program was launched in 2010.

    Methodology: A phenomenological design was conducted in Nyimba district. All nine CHAs deployed in Nyimba district were interviewed in-depth on their experiences of navigating the introduction of SRH services for youth in community settings, and the data obtained analyzed thematically.

    Results: In delivering SRH services targeting youth, CHAs worked with a range of community actors, including other health workers, safe motherhood action groups, community health workers, neighborhood health committees, teachers, as well as political, traditional and religious leaders. CHAs delivered SRH education and services in health facilities, schools, police stations, home settings, and community spaces. They used their health facility service delivery role to gain trust and entry into the community, and they also worked to build relationships with other community level actors by holding regular joint meetings, and acting as brokers between the volunteer health workers and the Ministry of Health. CHAs used their existing social networks to deliver SRH services to adolescents. By embedding the provision of information about SRH into general life skills at community level, the topic's sensitivity was reduced and its acceptability was enhanced. Further, support from community leaders towards CHA-driven services promoted the legitimacy of providing SRH for youth. Factors limiting the acceptability of CHA services included the taboo of discussing sexuality issues, a gender discriminatory environment, competition with other providers, and challenges in conducting household visits.

    Conclusion: Strengthening CHAs' ability to negotiate and navigate and gain acceptability in the community health system as they deliver SRH, requires support from both the formal health system and community networks. Limitations to the acceptability of CHA-driven SRH services are a product of challenges both in the community and in the formal health system.

  • 134. Zulu, Joseph M
    et al.
    Michelo, Charles
    Msoni, Carol
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Byskov, Jens
    Blystad, Astrid
    Increased fairness in priority setting processes within the health sector: the case of Kapiri-Mposhi District, Zambia2014Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, s. 75-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The challenge of priority setting (PS) in health care within contexts of severe resource limitations has continued to receive attention. Accountability for Reasonableness (AFR) has emerged as a useful framework to guide the implementation of PS processes. In 2006, the AFR approach to enhance legitimate and fair PS was introduced by researchers and decision makers within the health sector in the EU funded research project entitled 'Response to Accountable priority setting for Trust in health systems' (REACT). The project aimed to strengthen fairness and accountability in the PS processes of health systems at district level in Zambia, Tanzania and Kenya. This paper focuses on local perceptions and practices of fair PS (baseline study) as well as at the evolution of such perceptions and practices in PS following an AFR based intervention (evaluation study), carried out at district level in Kapiri-Mposhi District in Zambia. Methods: Data was collected using in depth interviews (IDIs), focus group discussions (FGDs) and review of documents from national to district level. The study population for this paper consisted of health related stakeholders employed in the district administration, in non-governmental organizations (NGO) and in health facilities. Results: During the baseline study, concepts of legitimacy and fairness in PS processes were found to be grounded in local values of equity and impartiality. Government and other organizational strategies strongly supported devolution of PS and decision making procedures. However, important gaps were identified in terms of experiences of stakeholder involvement and fairness in PS processes in practice. The evaluation study revealed that a transformation of the views and methods regarding fairness in PS processes was ongoing in the study district, which was partly attributed to the AFR based intervention. Conclusions: The study findings suggest that increased attention was given to fairness in PS processes at district level. The changes were linked to a number of simultaneous factors among them the concepts introduced by the present project with its emphasis on fairness and enhanced participation. A responsive leadership that was increasingly accountable to its operational staff and communities emerged as one of the key elements in driving the processes forward.

  • 135.
    Zulu, Joseph Mumba
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Michelo, Charles
    Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
    Innovation in health service delivery: integrating community health assistants into the health system at district level in Zambia2015Inngår i: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, s. 38-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: To address the huge human resources for health gap in Zambia, the Ministry of Health launched the National Community Health Assistant Strategy in 2010. The strategy aims to integrate community-based health workers into the health system by creating a new group of workers, called community health assistants (CHAs). However, literature suggests that the integration process of national community-based health worker programmes into health systems has not been optimal. Conceptually informed by the diffusion of innovations theory, this paper qualitatively aimed to explore the factors that shaped the acceptability and adoption of CHAs into the health system at district level in Zambia during the pilot phase. Methods: Data gathered through review of documents, 6 focus group discussions with community leaders, and 12 key informant interviews with CHA trainers, supervisors and members of the District Health Management Team were analysed using thematic analysis. Results: The perceived relative advantage of CHAs over existing community-based health workers in terms of their quality of training and scope of responsibilities, and the perceived compatibility of CHAs with existing groups of health workers and community healthcare expectations positively facilitated the integration process. However, limited integration of CHAs in the district health governance system hindered effective programme trialability, simplicity and observability at district level. Specific challenges at this level included a limited information flow and sense of programme ownership, and insufficient documentation of outcomes. The district also had difficulties in responding to emergent challenges such as delayed or non-payment of CHA incentives, as well as inadequate supervision and involvement of CHAs in the health posts where they are supposed to be working. Furthermore, failure of the health system to secure regular drug supplies affected health service delivery and acceptability of CHA services at community level. Conclusion: The study has demonstrated that implementation of policy guidelines for integrating community-based health workers in the health system may not automatically guarantee successful integration at the local or district level, at least at the start of the process. The study reiterates the need for fully integrating such innovations into the district health governance system if they are to be effective.

  • 136.
    Zulu, Joseph Mumba
    et al.
    Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia .
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Michelo, Charles
    Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia .
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Developing the national community health assistant strategy in Zambia: a policy analysis2013Inngår i: Health Research Policy and Systems, ISSN 1478-4505, E-ISSN 1478-4505, Vol. 11, s. 24-Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In 2010, the Ministry of Health in Zambia developed the National Community Health Assistant strategy, aiming to integrate community health workers (CHWs) into national health plans by creating a new group of workers, called community health assistants (CHAs). The aim of the paper is to analyse the CHA policy development process and the factors that influenced its evolution and content. A policy analysis approach was used to analyse the policy reform process.

    METHODOLOGY: Data were gathered through review of documents, participant observation and key informant interviews with CHA strategic team members in Lusaka district, and senior officials at the district level in Kapiri Mposhi district where some CHAs have been deployed.

    RESULTS: The strategy was developed in order to address the human resources for health shortage and the challenges facing the community-based health workforce in Zambia. However, some actors within the strategic team were more influential than others in informing the policy agenda, determining the process, and shaping the content. These actors negotiated with professional/statutory bodies and health unions on the need to develop the new cadre which resulted in compromises that enabled the policy process to move forward. International agencies also indirectly influenced the course as well as the content of the strategy. Some actors classified the process as both insufficiently consultative and rushed. Due to limited consultation, it was suggested that the policy content did not adequately address key policy content issues such as management of staff attrition, general professional development, and progression matters. Analysis of the process also showed that the strategy might create a new group of workers whose mandate is unclear to the existing group of health workers.

    CONCLUSIONS: This paper highlights the complex nature of policy-making processes for integrating CHWs into the health system. It reiterates the need for recognising the fact that actors' power or position in the political hierarchy may, more than their knowledge and understanding of the issue, play a disproportionate role in shaping the process as well as content of health policy reform.

  • 137.
    Zulu, Joseph Mumba
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Michelo, Charles
    Department of Public Health, School of Medicine, University of Zambia, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Hope and despair: community health assistants' experiences of working in a rural district in Zambia2014Inngår i: Human Resources for Health, ISSN 1478-4491, E-ISSN 1478-4491, Vol. 12, nr 1, artikkel-id 30Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In order to address the challenges facing the community-based health workforce in Zambia, the Ministry of Health implemented the national community health assistant strategy in 2010. The strategy aims to address the challenges by creating a new group of workers called community health assistants (CHAs) and integrating them into the health system. The first group started working in August 2012. The objective of this paper is to document their motivation to become a CHA, their experiences of working in a rural district, and how these experiences affected their motivation to work.

    METHODS: A phenomenological approach was used to examine CHAs' experiences. Data collected through in-depth interviews with 12 CHAs in Kapiri Mposhi district and observations were analysed using a thematic analysis approach.

    RESULTS: Personal characteristics such as previous experience and knowledge, passion to serve the community and a desire to improve skills motivated people to become CHAs. Health systems characteristics such as an inclusive work culture in some health posts motivated CHAs to work. Conversely, a non-inclusive work culture created a social structure which constrained CHAs' ability to learn, to be innovative and to effectively conduct their duties. Further, limited supervision, misconceptions about CHA roles, poor prioritisation of CHA tasks by some supervisors, as well as non- and irregular payment of incentives also adversely affected CHAs' ability to work effectively. In addition, negative feedback from some colleagues at the health posts affected CHA's self-confidence and professional outlook. In the community, respect and support provided to CHAs by community members instilled a sense of recognition, appreciation and belonging in CHAs which inspired them to work. On the other hand, limited drug supplies and support from other community-based health workers due to their exclusion from the government payroll inhibited CHAs' ability to deliver services.

    CONCLUSIONS: Programmes aimed at integrating community-based health workers into health systems should adequately consider multiple incentives, effective management, supervision and support from the district. These should be tailored towards enhancing the individual, health system and community characteristics that positively impact work motivation at the local level if such programmes are to effectively contribute towards improved primary healthcare.

  • 138.
    Zulu, Joseph Mumba
    et al.
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa. Department of Public Health, School of Medicine, University of Zambia, P.O. Box 50110, Lusaka, Zambia.
    Kinsman, John
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Michelo, Charles
    Univ Zambia, Sch Med, Dept Publ Hlth, Lusaka, Zambia.
    Hurtig, Anna-Karin
    Umeå universitet, Medicinska fakulteten, Institutionen för folkhälsa och klinisk medicin, Epidemiologi och global hälsa.
    Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries2014Inngår i: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, nr 1, artikkel-id 987Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Despite the development of national community-based health worker (CBHW) programmes in several low- and middle-income countries, their integration into health systems has not been optimal. Studies have been conducted to investigate the factors influencing the integration processes, but systematic reviews to provide a more comprehensive understanding are lacking.

    METHODS: We conducted a systematic review of published research to understand factors that may influence the integration of national CBHW programmes into health systems in low- and middle-income countries. To be included in the study, CBHW programmes should have been developed by the government and have standardised training, supervision and incentive structures. A conceptual framework on the integration of health innovations into health systems guided the review. We identified 3410 records, of which 36 were finally selected, and on which an analysis was conducted concerning the themes and pathways associated with different factors that may influence the integration process.

    RESULTS: Four programmes from Brazil, Ethiopia, India and Pakistan met the inclusion criteria. Different aspects of each of these programmes were integrated in different ways into their respective health systems. Factors that facilitated the integration process included the magnitude of countries' human resources for health problems and the associated discourses about how to address these problems; the perceived relative advantage of national CBHWs with regard to delivering health services over training and retaining highly skilled health workers; and the participation of some politicians and community members in programme processes, with the result that they viewed the programmes as legitimate, credible and relevant. Finally, integration of programmes within the existing health systems enhanced programme compatibility with the health systems' governance, financing and training functions. Factors that inhibited the integration process included a rapid scale-up process; resistance from other health workers; discrimination of CBHWs based on social, gender and economic status; ineffective incentive structures; inadequate infrastructure and supplies; and hierarchical and parallel communication structures.

    CONCLUSIONS: CBHW programmes should design their scale-up strategy differently based on current contextual factors. Further, adoption of a stepwise approach to the scale-up and integration process may positively shape the integration process of CBHW programmes into health systems.

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